Management of Normal Labour

Introduction and Definition of Normal Labour

Normal labour, also known as parturition, is the physiological process by which the fetus, placenta, and membranes are expelled from the uterus through the vagina. To be classified as normal or eutocia, several key criteria must be met:

• Gestational age: Term delivery occurring between 37 and 42 completed weeks.
• Onset: Spontaneous in nature without artificial induction.
• Presentation: Cephalic presentation with the occiput leading.
• Duration: Completed within a reasonable timeframe without undue prolongation.
• Outcome: Results in the birth of a healthy live infant and delivery of the placenta without maternal complications.

Understanding this definition helps midwives and nurses differentiate physiological birth from pathological dystocia early, preventing unnecessary medical interventions.

Stages of Labour and Physiology

Labour progresses through four distinct physiological stages, each driven by coordinated uterine contractions and hormonal changes.

1. First Stage: Begins with the onset of true uterine contractions and ends with full cervical dilation at 10 centimeters. It is subdivided into a latent phase of slow cervical change and an active phase of rapid dilation.
2. Second Stage: Lasts from full cervical dilation until the complete expulsion of the fetus. Maternal pushing efforts combine with uterine contractions to move the baby through the birth canal.
3. Third Stage: Extends from the birth of the newborn until the complete delivery of the placenta and fetal membranes.
4. Fourth Stage: Covers the immediate postpartum period, typically the first two hours after placental delivery, focusing on maternal stabilization and monitoring for haemorrhage.

Admission Assessment and Initial Evaluation

The initial evaluation upon admission establishes a baseline for maternal and fetal well-being. The midwife must greet the woman respectfully, take a focused obstetric history, and assess vital signs.

Abdominal examination determines fetal lie, presentation, position, and engagement using Leopold's manoeuvres. Auscultation of the fetal heart rate provides immediate reassurance of fetal status. A sterile speculum or digital vaginal examination assesses cervical dilation, effacement, membrane status, and station of the presenting part, provided there is no active bleeding from a suspected placenta praevia.

First Stage of Labour: Monitoring and Care

Continuous support and vigilant monitoring during the first stage ensure timely detection of deviations from normal progress.

• Maternal Vital Signs: Monitor blood pressure and pulse every four hours during the latent phase, and more frequently in the active phase. Assess temperature every four hours.
• Fetal Monitoring: Auscultate the fetal heart rate immediately after a contraction every 30 minutes in the active phase.
• Contraction Assessment: Check frequency, duration, and strength of contractions every 30 minutes.
• Urine Output: Encourage regular voiding every two hours to prevent bladder distension, which can obstruct the descent of the fetal head.

Providing continuous emotional encouragement and maintaining adequate hydration are fundamental nursing responsibilities throughout this phase.

Second Stage of Labour: Conduct of Delivery

The second stage requires active attendance as the baby moves through the birth canal. Position the mother in a comfortable upright or lateral position rather than flat on her back, which can cause aortocaval compression.

As the fetal head crowns, protect the perineum with controlled gentle pressure to minimize severe tearing. Instruct the woman to push with contractions using her natural bearing-down reflex rather than sustained, closed-glottis Valsalva pushing, which reduces maternal fatigue and maintains oxygen transfer to the fetus. Once the head is born, check for a nuchal cord around the neck, gently slip it over the head if present, and facilitate the delivery of the anterior and posterior shoulders.

Third Stage of Labour and AMTSL

Active Management of the Third Stage of Labour (AMTSL) is a vital intervention that prevents postpartum haemorrhage, the leading cause of maternal mortality in Nigeria. AMTSL consists of three essential steps:

1. Uterotonic Administration: Administer 10 international units of oxytocin intramuscularly within one minute of the baby's birth after ruling out a second twin.
2. Controlled Cord Traction: Apply gentle traction on the cord while simultaneously counter-applying suprapubic pressure to support the uterus.
3. Uterine Massage: Massage the uterine fundus immediately after the placenta is delivered and check every 15 minutes to ensure it remains contracted.

Neglecting AMTSL drastically increases the risk of atonic postpartum haemorrhage.

Fourth Stage of Labour and Immediate Postpartum Care

The fourth stage of labour is a critical transition period spanning the first two hours after placental delivery. During this time, the mother's physiological systems begin to stabilize.

Check maternal vital signs, uterine tone, and lochial blood loss every 15 minutes for the first hour, and every 30 minutes for the second hour. Encourage early skin-to-skin contact between mother and newborn to promote thermoregulation, bonding, and successful early initiation of breastfeeding. Inspect the perineum carefully and repair any lacerations or episiotomies with local anaesthesia. Ensure the bladder empties adequately to prevent secondary postpartum haemorrhage caused by uterine atony.

Documentation and Partograph Utilization

The partograph is a standardized graphical tool used to record maternal and fetal observations during active labour. It serves as an early warning system to identify prolonged labour and fetal distress.

• Alert Line: A line starting at 4 cm dilation representing a rate of cervical dilation of 1 cm per hour. Crossing this line signals a warning that labour is slower than normal.
• Action Line: A line parallel to and 4 hours to the right of the alert line. If cervical dilation crosses this line, immediate medical intervention or transfer to a comprehensive emergency obstetric care facility is mandatory.
• Record Keeping: Document all medications, pulse, blood pressure, contractions, and urine output accurately to maintain a legal and clinical timeline of care.